We report the case of a 34-year-old Malay, admitted for constipation and abdominal pain at 35 weeks of gestation. Initially, she was diagnosed to have paralytic ileus and was managed conservatively. As her condition did not improve, emergency laparotomy was performed for suspected intestinal obstruction. She delivered a baby boy weighing 2.84kg with good Apgar score through a caesarean section. Intra-operatively, she was noted to have sigmoid volvulus and sigmoidopexy was performed. Post-partum, colonoscopy and bowel decompression was performed. She recovered well and was discharged on day 5. This case illustrates the need to diagnose or suspect volvulus in pregnant woman presenting with severe constipation as early surgical intervention can reduce morbidity to both mother and fetus.
Desmoplastic small round cell tumour (DSRCT) is a very rare malignant tumour which commonly presented as an
intraabdominal tumour. It has a distinct histological and immunophenotypic characteristic which differentiates it
from other types of small blue cell tumour such as Ewing’s sarcoma, primitive neuroectodermal tumour,
neuroblastoma and malignant mesothelioma. Apart from the abdomen, it may also originate from other region of the
body including the reproductive organs.
Gastrointestinal stromal tumour (GIST) is extremely rare with reported incidence of 20 per million per year. It is the most common mesenchymal tumour of the gastrointestinal tract. When it occurs at the pelvis in a female patient, it can be misleading to a gynaecological diagnosis. Non gynaecological diagnosis such as GIST must be considered in patients with pelvic mass presenting with atypical symptoms.
This was a 28-year-old mentally-challenged girl with underlying congenital Rubella syndrome. She was bilaterally aphakic after congenital cataract surgery. She then developed bilateral aphakic glaucoma and had to undergo multiple glaucoma filtering surgeries. The most recent procedure she had undergone for her left eye was a second Ahmed valve implantation with an overlying sclera patch. Postoperatively, intraocular pressure was well controlled. However, nine months later, slit lamp examination revealed the tube was adherent to the overlying cornea with surrounding deep and superficial cornea vascularization. Siedel test was negative and intraocular pressure was normal. Subsequently the tube was removed but the plate was left in situ.
Congenital peritoneal band is an extremely rare condition, but may induce small bowel obstruction (SBO) at any age, predominantly in childhood and rarely in adults. We report a case of extensive bowel ischaemia following caesarean section, due to trapping of an intestinal loop between a congenital peritoneal band and the mesentery. A 42-year-old, Gravida 2 Para 1, who has no history of prior abdominal surgery or trauma, presented in spontaneous labour and underwent an uncomplicated emergency lower segment caesarean section, for fetal distress. Postoperatively, she had worsening abdominal distension and pain, followed by vomiting. Computed Tomography Scan of the abdomen showed gross fluid retention with marked small bowel dilatation and fluid filled bowel loops. An emergency exploratory laparotomy was performed which revealed a congenital band, extending between the right fimbrial end and the small bowel mesentery, looping over the small bowel, causing extensive small bowel ischemia. Post-operative course was uneventful. In conclusion, congenital peritoneal band causing small bowel obstruction, although rare, should be considered in the differential, especially for patients with virgin abdomen.
We report on a rare case of a child with persistent right upper lid eversion with conjunctival prolapse since birth that
failed various attempts in repositioning the right superior fornix at other centre. He was found to have a right superotemporal
orbital mass above the prolapsed area. Computerized tomography (CT) scan of orbit confirmed a right
lacrimal gland tumour with thinning of the right lesser wing of sphenoid. An excision biopsy of the tumour via
anterior orbitotomy and eyelid reconstruction were performed. Histopathology report reviewed plexiform
neurofibroma of the lacrimal gland. Further physical examination confirmed presence of multiple café-au-lait spots.
He was diagnosed as Neurofibromatosis Type 1.
A 21-year-old Chinese gentleman with no known medical illness, presented with a history of right painless blurring of vision with central scotoma of two weeks duration. He also had a history of multiple episodes of seizures prior to presentation. Visual acuity was 1/60 with unremarkable anterior segment findings and no relative afferent pupillary defect. Fundus examination of the right eye revealed dilated and tortuous retinal veins with multiple retinal capillary hemangiomas and sub retinal hard exudates at the macula with edema. A diagnosis of Von Hippel Lindau disease was made when a posterior fossa mass suggestive of hemangioblastoma with obstructive hydrocephalus was seen on computed tomography of the brain. Craniotomy with nodule excision was performed. The retinal capillary hemangiomas were treated with the combination of laser photocoagulation and intravitreal Ranibizumab injections. Visual acuity subsequently improved to 6/36.
An 18-year-old Malay gentleman was noted to have profound bilateral blurred vision for one month duration, associated with loss of weight, appetite, low grade fever and abdominal distension. Visual acuity on presentation was 6/60 on the right, counting finger on the left with no afferent pupillary defect. Anterior segments were unremarkable. Vitreous cells were occasional bilaterally. Fundus revealed multiple choroidal and sub-retinal Roth spots with areas of pre-retinal and intra-retinal haemorrhages, involving the macula in the left eye. Vessels were dilated and tortuous in all quadrants of the right eye. Many areas of capillary fall out at peripheral retina were demonstrated in fundus fluorescein angiogram. Further systemic and laboratory review confirmed the diagnosis of CML and chemotherapy was initiated. Both eye ischaemic retinopathy secondary to CML was confirmed and scatter pan retinal photocoagulation was performed bilaterally. Good improvement in vision noted during subsequent follow up to 6/24 on the right, 6/60 on the left. High levels of suspicion and accurate early recognition of fundus changes are vital in these types of cases to ensure the institution of prompt treatment.
Phacoemulsification (PEA) is currently the procedure of choice for most cataract extraction. However, intra-operative complications may require the procedure to be converted to extracapsular cataract extraction (ECCE). We have evaluated the indications for conversion and visual outcomes in cases converted from phacoemulsification to ECCE. A retrospective review was performed on 33 eyes in which phacoemulsification was initiated and then converted to ECCE. The main parameters evaluated were indications for conversion and visual outcomes at 3 months. Thirty-three cases out of 1448 operations were identified from January 2013 to February 2014.The incidence of PEA converted to ECCE was 2.2%. The indications for ECCE conversion were posterior capsular rupture (PCR) in twenty-two cases, combined capsulorhexis extension with PCR in three cases, capsulorhexis extension and zonular dialysis in two cases respectively. Combined zonular dialysis with PCR, corneal toxicity, Descemet’s tear and obscured edge of capsulorhexis had one case each. Twenty-six (78%) cases had gain in vision, one (3%) case had unchanged vision and six (18%) cases had worsening of vision. The incidence of complicated phacoemulsification surgery requiring intra-operative conversion to ECCE was low in our study (2.2%). Seventy-eight percent of cases achieved final VA of 6/12 or better. Therefore, early recognition of complications and timely intra-operative conversion of PEA to ECCE may result in good visual outcome.
Surgical training worldwide has been reformed from
the since 19th century until the present era. It started as
a trade which eventually was transformed into a
profession that acquires skills and knowledge. The
apprenticeship model was introduced amongst the
Western surgeons as the standard approached for
surgical training. The surgery was learned through
direct observation without any formal and structured
education. William S Halstead had introduced the new
approach of training the surgeons in America
following his landmark lecture at Yale University in
1904 (1). His principle was based on direct the
German Surgical training which emphasized on basic
sciences in the curriculum and Sir William Ossler
concepts of bedside rounds. This has lead to the
development of Halsted principals of surgical training
which included intense and repetitive exposure in
managing surgical patients under the supervision of
skilled surgeons, acquiring the knowledge of scientific
basis of surgical diseases and as the surgical trainee
received enhanced responsibility and independence
with each advancing year (2). Since then, Halsted
principle of surgical training has become the
foundation of most established surgical training
worldwide. The principles have been expanded and
upgraded and since then six cores competencies have
been identified for the surgical residents to achieve
and master during the training course (3). There were
medical knowledge, patient care, interpersonal and
communication skills, professionalism, practice-based
learning and improvement and system based practice.
From the Malaysia perspective, surgical training was
done through the overseas Royal colleges after the
independence in 1957. The local programme started in
1982 through the initiative of local universities that
initially offered surgical training programme in
General surgery, Orthopedics and otorhinolaryngology
(4). Since then through the collaborations of Ministry
of Health and other professional bodies various
surgical training programme has been established to
provide training opportunities which will eventually
serving the nation. The subcommittee of the National
Conjoint Board for General Surgery was the
consultative body to oversee and manage the
implementation of the surgical training. Since the
establishment, the subcommittee was responsible in
streamlined the training curriculum for all the
universities that offered the course, centralized and
standardized the intake of the trainees, coordinating
the national exit examination and advising new
application for graduate training in general surgery.
The important milestone of the subcommittee was the
task given to develop the national surgical
postgraduate curriculum for the doctors who are
interested in becoming a surgeon in the country. The
curriculum is being developed to create a pathway for
surgical training from the internship until subspecialty
training. The development encompasses the
governance, the curriculum development, the training
process and learning outcome according to the latest
evidence based on post graduate training. The
programme should be the foundation in producing well
trained surgeons towards 2050 through TN50.
Placenta previa is a condition when the placental tissue extends over the internal cervical os. It is associated with
maternal and fetal morbidity and mortality. With intrauterine death, the mode of delivery will be more difficult to
decide. Here, we report a case of 30 years old G3P2 with placenta previa major diagnosed with intrauterine death at
29 weeks gestation who was managed conservatively and delivered vaginally with minimal complication. A good
patient selection and thorough counseling, patient with placenta previa major and intrauterine death still can be safely
delivered vaginally.
A congenital urethrocutaneous fistula is a rare anomaly which was first described in 1962 by Gupta. Clinically, children present when their guardian is alarmed by either frequent urinary dribbling or unusual stream when they pass urine. This congenital anomaly can present in isolation or be accompanied by a chordee, hypospadia and anorectal malformations in a newborn. The surgical management will either be a primary repair of the fistula or converting it to a hypospadia before proceeding with a single or staged hypospadia repair. Surgical technique will depend on the local tissue factors and associated anomalies.
Thyroidectomy for benign and malignant diseases has progressed dramatically over the last two decades. Moving from large collar incision to no scar is a very good news to the patient with neck swellings. The morbidity of the surgery remains low regardless of the technique and approaches used but scarless surgery is still limited to benign diseases and small cancers. Further study and future refinement of the technique might make these techniques also applicable to large tumours.
Radiotherapy has been widely use as an adjuvant therapy in the breast cancer management. The usage has increased the incidence of radiation induce sarcoma. We here present a case of radiation induce sarcoma of the axilla following mastectomy and axillary lymph node dissection for infiltrating ductal carcinoma.
Penetrating injuries to bladder occur in 20 % of cases. Synchronous bladder and rectal perforation occur in 30-64 % of cases. The management of rectal and bladder injuries depend on whether it is an extra-peritoneal or intra-peritoneal injury. We hereby, report a case of penetrating trauma in a 13 year old boy who fell off a tropical fruit (Rambutan - Nephelium lappaceum) tree. He sustained an extra-peritoneal rectal injury with intra-peritoneal bladder injury. The rectal injury was repaired primarily via per anal route while the bladder injury needed an open repair following laparotomy. Upon removal of bladder clots, a leaf of the ‘Rambutan’ tree was found intra-vesically. It was removed and bladder repaired as per standard method. We review the literature on rare intra-vesicle foreign bodies and discuss the treatment of synchronous rectal and bladder injuries.
Platinum based adjuvant chemotherapy is generally recommended for ovarian cancer to improve the survival rate. Intravenous route is commonly used, easily administered and less associated complications. However, intraperitoneal route is gaining its popularity as a single procedure or adjunctive to the intravenous route. Numerous questions on its eligibility and safety are still perplexed. A case review on a patient with non optimal debulking surgery of advanced ovarian cancer was studied. Intravenous platinum based chemotherapy combined with paclitaxel failed to bring her to clinical remission. Second line chemotherapy, gemcitabin rendered her to poor response with unresolved debilitating ascites needing recurrent drainage. Surprisingly, a trial of intraperitoneal chemotherapy with cisplatin revealed a great response with a complete clinical remission.
Fulminant haemorrhage in cervical cancer leads to severe anaemia and haemodynamic instability. Palliative management includes vaginal packing as temporary measure, radiotherapy and other invasive surgical procedures. High dose emergency chemotherapy is not commonly implemented particularly when complicated with anaemia and renal impairment. We discuss three case series on the usefulness of high dose chemotherapy to combat bleeding from cervical cancer as an emergency treatment. The first case was clinically staged as operable 2A disease with severe anaemia due to bleeding from the tumour mass. The haemoglobin was corrected by blood transfusion while the bleeding was being arrested by high dose chemotherapy. The second case was inoperable with invasion to the bladder mucosa. She had frank haematuria and bleeding from the tumour with severe anaemia. A course of chemotherapy and blood transfusion controlled the bleeding and anaemia was corrected. The third case presented late with obstructive uropathy and anaemia. She required dialysis, blood transfusion and high dose emergency chemotherapy to stop the bleeding before undergoing urinary diversion after an unsuccessful ureteric stenting. High dose chemotherapy consisting cisplatin, vincristine, bleomycin and mitomycin-C has a clinical value in arresting fulminant haemorrhage in cervical cancer.
A 28-year-old G3P1+1 at 6 weeks period of amenorrhea with a previous Caesarean section presented with per vaginal bleeding. A cervical ectopic pregnancy was confirmed by a transvaginal scan. An intramuscular methotrexate was given followed by intracervical route due to poor decline of the serum βHCG. However, due to persistent increment of serum βHCG, an additional four doses of intramuscular methotrexate with folinic acid rescue were administered and she responded well to the regime. Unfortunately, following the last dose, she developed an episode of excessive per vaginal bleeding which required suction and curettage of the cervical canal. A Foley‘s catheter balloon was placed intracervically as a tamponade and the bleeding was successfully arrested.
Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.
A surgeon’s experience plays an important role in breast conserving surgery (BCS). The common conception is that, the more junior is the operating surgeon, the surgical margin will be wider or closer to the tumour edge. Thus the aim of this study is to look into the adequacy of surgical margin performed by different level of surgeons’ experience in patients whom underwent wide local excision (WLE) and hook-wire localization (HWL) in our surgical unit. The surgical experience of the operating surgeon and their surgical margins will be analyzed. This is a retrospective study from January 2000 to December 2012. Eighty-eight patients with early breast cancer underwent WLE and HWL by 3 different groups of surgeons (breast surgeons, junior surgeons and surgical registrars) were included. The surgical margins were analyzed for involved-margin, closed-margin or excessed-margin.The incidence of involved-margin, closed-margin and excessed-margin is the lowest among breast surgeons compared to other groups. However, the results were not statistically significant. The incidence of involved surgical margin is significantly higher within junior surgeons for HWL compared to the breast surgeons. The incidence of involved, closed or excessed surgical margin were lowest when performed by breast surgeon but not significantly different between the three groups. However, for HWL the breast surgeons significantly better compared to the other groups.